Provider Demographics
NPI:1114514742
Name:SMITH, ELLA ILIANA (QMHA, CADC I)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:ILIANA
Last Name:SMITH
Suffix:
Gender:F
Credentials:QMHA, CADC I
Other - Prefix:
Other - First Name:ELLA
Other - Middle Name:ILIANA
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA, CADC I
Mailing Address - Street 1:6025 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1927
Mailing Address - Country:US
Mailing Address - Phone:866-262-0531
Mailing Address - Fax:
Practice Address - Street 1:6025 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1927
Practice Address - Country:US
Practice Address - Phone:866-262-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)